Viremic – Cases in HIV

Announcer:
Welcome to Viremic–Cases in HIV, a podcast that explores quandaries in adult HIV clinical care. In each episode, Drs. Eileen Scully and Christopher Hoffman, HIV specialists at Johns Hopkins, discuss a case, review challenges in the plan of care, and highlight evidence and guidelines that inform clinical decision-making. Now, here is your host, Eileen Scully.

Dr. Eileen Scully:
Well, hello everyone and welcome to Viremic. This week we have a special treat. I’m joined by a guest and friend of the podcast, Dr. Matthew Hamill. Dr. Hamill was trained in the UK, is an expert infectious disease physician, and fortunately for me, also has clinic on Monday afternoons. I can often walk down the hall to ask for his input on challenging cases. I’m really excited to welcome him today and I have a challenging case for him.

But before we start with that, Dr. Hamill, do you want to introduce yourself to the Viremic listeners?

Dr. Matthew Hamill:
Thank you for the kind invitation, number one, and for the generous introduction. It’s a real pleasure to spend some time with you today to contribute a little bit about sexually transmitted infections other than HIV to this wonderful podcast, Viremic, which I’m certainly a fan of and am learning as I drive my car and my daughter into school and home from school on a Thursday evening. Thank you for asking me to take part.

As you said, I was trained in the UK. I’ve specialized in providing care for people with or at risk of sexually transmitted infections, including HIV, for the past 25 years.

Eileen:
I’m going to dive right into our case. Today we’re going to be talking about a composite patient who I will give some details about. This is a 32-year-old gentleman, has a history of HIV and is currently on bictegravir/ emtricitabine/TAF, and his HIV is well controlled. He does not have any other significant comorbid conditions—actually exercises regularly, takes his ART, and generally is doing very well.

He had previously been in a relatively long-term relationship, about 8 years, with one man, until about 6 months ago when that relationship ended. Since that time, he’s been sexually active with several new partners, all of whom are male.

He presents today for a routine visit for HIV care, and you’ve been providing HIV care for some time. His last sexually transmitted infection screening was actually 3 years ago, and he declined at prior visits due to his stable relationship. And at today’s visit, he reports he’s generally feeling well, and [in] a detailed review of symptoms, he does say he’s been having some headaches recently, but he thinks maybe his vision has changed and he should probably get his glasses updated. Otherwise, he’s tolerating his medication, which is the Biktarvy only. He has 100% adherence and no other symptoms that he’s noted and just requests that everything be checked out.

Basic labs are done at this visit, and his HIV safety and efficacy parameters are all excellent with a fully suppressed viral load and no signs of concerns in his renal function or his blood count. He had 3-site screening—throat, rectal, and urine—all of which were negative for gonorrhea and chlamydia. And his serum treponemal antibody returned positive, with the follow-up RPR at 1 to 64.

That’ll be the case we’ll start with. At this point, I’d like to pause and ask you a few questions. First of all, if you could just review for us your approach to STI screening and how you talk to patients about risk in general.

Matthew:
Thank you, Eileen. It’s a really interesting case. It’s very familiar to me in my clinical practice. In terms of how I discuss STI screening with patients, I really use an individualized approach. I’m informed and try to adhere to, as best possible, the CDC screening guidelines, which are very helpful. They will help to guide us to try and figure out which particular tests we should be offering to patients based on sexual behaviors and anatomical exposure. What the CDC do[es] is provide 2 sets of guidelines. One is what’s called a disease-based screening algorithm, for example, Chlamydia trachomatous or Neisseria gonorrhea. And then they’ll also provide a population-informed screening process. I find that one very helpful when thinking about people who are living with HIV. You can go onto the CDC STD treatment guidelines and look for screening recommendations; that will be one of the hits that you will find if you use a search engine.

What I won’t do at this point is to go through each and every organism that we might screen for. What you’ve said already, Eileen, is incredibly helpful; you talked about this individual having triple site testing for chlamydia and gonorrhea. That, of course, will be based on a sexual history to understand which anatomical sites may have been exposed so we can then offer the appropriate screening based on that anatomical exposure.

Talking about risk is something, again, that I individualize. I’m mindful of the fact that despite the work that you and I, this podcast and others do, that sexually transmitted infections, including HIV, remain stigmatized. People can feel awkward and embarrassed about providing a sexual history. So, coming at it from a place of humility and respect is a good place to start. Rather than talk about risk, I ask people to unfold their story, to tell me about the kind of sex they’re having, whether it’s in this situation, oral sex, anal sex, both, whether they’re the insertive or the receptive partner, or both, and then have an idea rather of the number of sex partners that they’ve had in, for example, the last 3 months. Then we’ll follow it up with things like, “Typically, do you use condoms?” Or, more specifically, “The last time you had anal sex where you were the receptive partner, did you use a condom in that situation?” So, it’s a bit of a mix of trying to allow the narrative to unfold, but also directing the conversation a little bit to give some anchors whereby the patient can provide you with specific examples.

Eileen:
One of the things that I’ve been very conscious of recently is this idea of “opt out” as opposed to “opt in,” with approaching testing as a very normal and routine exam to be done and offer the patient the option to decline, but not to say that they have to choose it because I feel like sometimes offering people to choose screening seems to suggest that they have to endorse a certain kind of behavior as opposed to saying, “This is what I do routinely for all of my patients,” but seems to land a little bit better.

Matthew:
Yeah, I think that’s a great way of summarizing—to normalize these tests. I remember 25 plus years ago when I first started working in sexual health and was inexperienced in those days. There’d be an intake of breath and a bit of a pause and then starting talking about screening for STIs rather than just rolling it in in a very natural way into the conversation, in the way that we talk about screening for cardiovascular disease, for example, for hypertension. I’m sorry, I should say for consequences of hypertension. It’s normal practice, and patients will expect us to be acting in their best interest. I think normalizing these tests is a very helpful way to proceed. Typically, what I will say is when I’m thinking about sexually transmitted infections, “I want to make sure that I’m testing the right part of your body,” and we’ll collect either a urine or a vaginal sample, depending on the person’s anatomy. Then I’ll also say, assuming that they endorse genital sex, and then we’ll also say, so we can do a throat swab and or a rectal swab. And we’ll then allow the patient to proceed from there so that they can, without having to really even go into their sexual history, they can tell me which test they would like on that particular day.

Eileen:
Well, that’s a perfect way for all of us to think about it. I remember one of the ways that I first learned to approach this was by bundling it with the general risk discussion, which also included the off-ramp question of, “You wear a seatbelt in the car?” And then people kind of giggle and you say, “Well, these are all the things that matter, and they’re normal behaviors. And we’re just trying to find out which ones of them are useful for your health.”

Matthew:
Yeah, I think that’s a really great way. I’m going to steal that one. I really like that idea of risk as a conversation opener and risk framed in a positive way like that. So, thinking about interventions that we can do to assist them to stay healthy and well in whatever dimension we’re looking at, whether it’s seat belts or smoking or sexually transmitted infections.

Eileen:
One other point in this case is that this person’s risk profile likely dramatically changed. They had previously declined screening, were in a monogamous relationship, and didn’t assess themselves to have any risk. A breakup can often be a point of emotional disruption and not exactly one where you might be thinking the first thing you would do would be to call your doctor. But I think in many of these cases, this is why having that relationship where you can talk about relationship status with your patients and find out when their risks change can become really important to providing whole person care.

Matthew:
Yes, I agree. And it’s also one of the reasons that the alerts on the electronic medical records can be so helpful. Our colleagues will or we can look at our own provider dashboards, for example, and see which of our patients haven’t had a syphilis test in the prior 12 months and then incorporating that into their next visit.

In summary, what I’m trying to say is that we can use all of these different tools—the normalization bit, the generalized risk reduction—to try and incorporate testing, prevention, and treatment for sexually transmitted infections into our regular consultations with our patients. The other thing I would like to mention here, Eileen, is to try and move away from the disease-based paradigm and try and think of it more as a health-seeking or healthy behavior paradigm, where we can talk about screening, behavior change, et cetera, in a way that absolutely does not feel punitive, that removes a sense of judgment and can really focus on other things like sexual pleasure, relationships, et cetera.

Eileen:
Let’s move on to thinking about what this particular test result means. To remind everyone, we had negative 3-site testing, but a positive screen for treponemal antibody, and an RPR of 1 to 64. The last available prior syphilis test was a negative treponemal antibody screen 3 years ago and another one at some point in the 10 years prior. Before we dive into the specifics of this case, can you walk us through the different types of syphilis tests that we use in clinical practice?

Matthew:
Sure. The way that I think about this is to divide them into two—it’s a branching logic that I use. Firstly, I’ll think about direct tests. So, what direct tests do we have access to to help us to diagnose infection with Treponema pallidum, the bacteria that causes syphilis? We have dark-field microscopy. If the institution where you work has access to a dark-field microscope (and it sounds much more difficult than it is; it just requires a different lens to turn a bright field into a dark-field microscope), then you can do a relatively straightforward, very cheap and sensitive test where you will take some fluid from a lesion, from typically a genital lesion and examine it under dark field, and you will be able to see the motile treponemes swimming along under the high power field. That’s one of the direct tests that’s great for primary lesions. It’s also really helpful if someone has moist secondary lesions such as condylomata, which are very rich indeed in bacteria.

The other direct test is PCR. I had certainly used PCR-based testing of genital lesions when I was working in the UK. Unfortunately, in the U.S., we don’t have any FDA-clear tests for PCR for t-pallidum. These are currently not available. There are laboratories that have developed research use-only tests. And there are other laboratories that will offer tests that that have not been approved or cleared by the FDA.

So, they’re some of the direct tests that we can use. Thinking about indirect tests for Treponema pallidum, largely we use serological tests to diagnose a syphilis infection. The serological tests are divided into two. There are the treponema-specific tests, and then there are the non-treponema tests, which are sometimes, and maybe more correctly, called “lipoidal” tests. These are not specific for treponemes; they are the antibodies to antigen that’s produced in response to t-pallidum infection. So, it’s possible to have false positive non-treponemal tests. When I say non-treponemal tests, I’m really talking about the rapid plasma reagent or RPR, although some institutions will use the VDRL test. They’re the two non-treponemal tests that we use in the U.S.

Eileen:
When we talk about these test results, this is one of those things that you learn as a medical student and then depending on how frequently you look at these tests, they can feel quite confusing when you encounter them again. Fortunately for us, we do see them fairly frequently, and for anybody who does not, the treponemal antibodies test, once positive, will remain positive in most individuals for life because it just indicates a prior exposure. That’s when we start to follow the RPR as one of the indicators of repeat infection because that will rise in the setting of a new infection or a resurgent infection from one that was previously incompletely treated.

Matthew:
As you’ve alluded to Eileen, the two different serological tests, the treponemal and the non-treponemal tests, they’re complementary, but they also have distinct functions, I should say. The treponemal test (the specific test) is great for diagnosis of syphilis in somebody who has never been diagnosed before. I say that because the treponemal test tends to become positive in early primary, so very early syphilis sooner than the non-treponemal test. So, you have an advantage there. And it also stays positive in most people lifelong, as you have just mentioned. Therefore, it will also allow us to diagnose people who’ve had syphilis for a long time, where their RPR or their non-treponemal test has faded over time. So, it has advantages on both ends—for early detection of syphilis and also for diagnosing people who may have had syphilis for a long time, but have not been adequately treated, but whose RPR has waned over time.

The non-treponemal tests, the RPR tests, again, they’re useful for diagnosis, but the beauty of them is that they will fall or they should fall following appropriate treatment and will rise again if the individual is reinfected or has treatment failure. We use the tests in tandem. But one thing that I like to try and communicate is that once somebody’s had a positive treponemal test, they never need it again if they’ve had a diagnosis of syphilis. The way that we manage serological follow-up is using the non-treponemal test only. The other reason that I say that is it can cause a lot of confusion for patients when they open up their electronic medical record and they see a test for syphilis and it says in red type “positive,” when all that’s happening is that treponemal test is reflecting a previous infection. It doesn’t reflect the current state of play. That’s where we use the RPR.

Eileen:
Exactly, and we all know that it’s important to not have results alarm patients. In our system, it didn’t use to be possible to order an RPR without the test—it was a reflex test—but we recently had (when I say recently, it’s been a few years) those tests unlinked. That allows us to order only the RPR in individuals who’ve had the positive treponemal antibody in the past, which avoids some of those problems you’re mentioning.

Now getting to the specifics of the test itself, when we see a positive treponemal antibody and a positive RPR with a pretty good long duration since a prior test, then questions arise about the duration of infection. One of the first things that comes to mind is, does the actual level of the RPR provide you any information about the recency of infection?

Matthew:
Yeah, I love this question. The reason that I love it is that I’m frequently asked about it. As human beings, we want to try and draw straight lines between things. It makes us feel better. But I really believe that we cannot be guided by the RPR titer in terms of how long the person has had an infection. The reason that I say that is that in order for us to have any sense about what the current RPR titer is, we need to know the peak titer of when that person was infected with syphilis.

So, let’s take this case, for example. The titer that you currently have is 1 to 64. People will say, “Well, that’s high,” which is slightly an arbitrary statement. So, we will anticipate that that person has recently been infected. But let’s say 5 years ago, this person had unrecognized secondary syphilis and their RPR titer was greater than one in a million (and such things do happen, believe it or not). Then a titer of 1 to 64 five years later really tells you nothing about the acuity of that, about the syphilis infection.

In places, practical decisions are made, and the CDC and their guidelines will refer to this. Some jurisdictions do say that a titer of greater than or equal to 1 to 32 provides some circumstantial evidence that this may be early infection. But my own practice is to not use the titer to persuade me one way or the other in the absence of a really good history and the absence of previous serological testing to adjudicate that this is a recent infection.

Eileen:
That’s what I thought you would say, maybe having been one of the people to ask you about this in the past.

Matthew:
And of course, the reason that I say that is because the way that we stage syphilis is critical for many reasons, but one of the reasons is it dictates the treatment that we will use. That’s why I think in many ways it’s important to be conservative, not for the sake of being conservative, but to make sure that we are offering the best possible treatment to the individual patient.

Eileen:
I agree. I was going to ask also, do you try to elicit from patients whether there was ever a lesion that would have been consistent with primary infection? And if they did say, well, there was kind of this funny thing, on my, I did have this funny genital lesion, but it didn’t hurt and went away. Do you give that weight in your consideration?

Matthew:
I do, actually. I mean, as with most of my responses, they will begin with, “it depends.” These things are very context dependent. But actually, I certainly do pay a lot of attention to the patient history because I think it can really help us. I think it can help us to narrow down the stage, whether this is a primary, secondary. And I think that if we can confidently say, this is an early primary or secondary syphilis, then we only need to treat this person with a single dose of a long acting benzathine penicillin or a 14-day course of doxycycline. That helps them to avoid unnecessary treatment. It also helps the health system because it reduces costs both in terms of medication, but also in terms of personnel time.

That was a long-winded way of saying yes, I do pay a lot of attention to the patient history, because sometimes you get an absolute classic history, as you were alluding to. “I had a single painless lesion when I pulled my foreskin back, and I poked it and prodded it and absolutely didn’t hurt. And it felt a bit raised at the edges, and I had some swelling in my groins at the same time.” To me, that is such a classic history of a primary lesion or a chancre that I would put great weight in that history. What the CDC says is that we need an unequivocal history of primary or secondary syphilis. And I think the art of medicine is how you determine what “unequivocal” means.

The other thing about a history of primary or secondary syphilis is to ask the patient, “Did you happen to take a picture of the rash? Did you happen to take a picture of the genital ulcer?” And it’s amazing how often people will say yes, and they’ll take out their phone, and they’ll show you. It’s one of those times with medical students or other learners that you can feel like a bit of a magician because they think, how did you ever think of that? But it’s just being realistic that people use the internet all of the time to try and get healthcare advice. So please do ask patients, “Did you happen to take a picture of the rash or of the lesion?” And then if they can show you something that looks absolutely classic secondary syphilis, then again, that can make you feel more reassured that the serology that you’re dealing with is in the context of secondary syphilis.

Eileen:
I’m going to continue to have you play the artist here because I think the next artist request is how we interpret the absence of any neurologic findings, which I think is another feature that often leads people to call you. Specifically, here, let’s talk about how, without necessarily staging this person, let’s say he doesn’t give us a great history of a primary shanker, and we have 3 years. We have a positive RPR. Again, even in my much more limited experience, I’ve seen much higher RPR titers than 1 to 64. To me, 1 to 64 is solid evidence of syphilis, but doesn’t give me much feeling about the recency of infection, whether it should or not. So, we have this unclear duration. We know he’s only been out of his relationship for 6 months. We don’t know if the reason for the end of that relationship was infidelity from his partner, for example. And we have an individual with well-controlled HIV. I didn’t give you a CD4 count, but we’ll make it robust.

At this visit, he made those vague comments about his headache and needing glasses, and maybe I didn’t do a neurologic exam. Why don’t you talk a little bit about how you think about neurosyphilis and who needs to have the CSF evaluation?

Matthew:
Yes, this is something that is perennially thorny. When patients have absolutely unequivocal, to use the CDC language, neurological signs on clinical examination in the context of positive syphilis serology, then that’s a very easy decision to make in conjunction with a patient. There’s no subtlety required. That person has neurological syphilis until proven otherwise.

The difficulty is when somebody is well, they have a headache that is not the worst headache that they’ve ever had or a particularly troublesome headache, but the headache is there. Feature of having some visual changes, some difference in visual acuity. These are the cases that are very challenging. What I mean by that is that what we as providers are asked to do in this scenario, of course, in conjunction with the patient and using shared decision making, is to decide does this person requires urgent referral to the emergency room or an urgent admission for same-day CSF examination or not.

Here, the history again so important. If the patient said, “These are the kind of headaches that I had in my 20s. I tend to have them when I’m stressed out. I’ve been a bit more stressed out recently.” And you really go into the details of the headache, and you find that these headaches are really very similar to a headache that the patient has previously had, then I’m not entirely reassured by that, but I’m much more reassured than if somebody says, “I never get headaches. I’m just not a headache person,” and then they have this new onset of headache in the context of a positive syphilis serology. So, I think being really clear about the congruity of the headache or other neurological symptoms and the time when this person likely became infected with syphilis is important.

Also thinking about the visual symptoms. Optic syphilis can cause any presentation practically. There’s nothing that’s pathognomonic of ocular or optic syphilis. Just remember that from the front of the eye all the way back to the optic nerve and everything in between is and can be affected by syphilis. It can mimic virtually every other ophthalmological condition. And then try and really focus with the patient on “When you say that you might need glasses, is it because there are some flashing lights, that there is dark spots in front of your eyes? Are your eyes painful when you move them, when you scan to read a page?” Just to try and have some more specific details rather than the umbrella term that I’m getting older, and I need to update my prescription.

The final thing I would say about neurological syphilis or otological syphilis, and I think this for me is the most difficult history to elicit because the symptoms can be really mild. Unless you specifically ask the patient, “Have you had any changes in your hearing? Experienced tinnitus or ringing in your ears or have you had any dizzy or unsteady spells?” then often the patient won’t report those symptoms because they perceive them to be quite mild.

Eileen:
I have to say that the otosyphilis screening in my practice has dramatically increased since the onset of Dr. Hamill’s presence at Johns Hopkins because it was definitely not something that I was well trained in before. So, I’m glad that we got that point out. That’s one of the things that I am grateful to have learned from you. But screening for that type of CNS involvement, definitely one of the things we need to consider.

Matthew:
Yes, I realized that that was an arabesque into different forms of neurological presentation. But the point I was trying to make is that it’s hard to get this right all of the time. And by right, I mean doing the thing that is best for the patient. When I’m in my own practice and when I’m working with learners, I’ll say that it’s great to be wrong about neurosyphilis; we don’t have to be right. We don’t have to have a 90% hit rate that if we refer someone to the ED, 90% of our patients will indeed turn out to have neurological involvement. It’s great in that scenario if we can be reassured that, in fact, they don’t have neurological involvement. It saves them a 10- to 14-day stay in an institution to receive intravenous penicillin. It allows them to get on with their lives, to be at work, to earn money.

It’s a really tough one to be absolutely confident that you’re sending the right person either to the emergency room or for an urgent admission for CSF exam versus the patient that you think, “They look fine, and I’ll see them again in a week. And if things change, then I can arrange maybe a non-urgent outpatient CSF examination so that everybody’s nerves are settled.”

Eileen:
For this particular case, we’ll say that there was a little bit too much concern that this was maybe something, and he did actually have a CSF examination that was negative. No pleocytosis and also a negative CSF VDRL.

Would you just walk us through how you would treat him?

Matthew:
Yes, this is a patient who doesn’t have neurological involvement based on the bland CSF, normal cell count, normal protein, negative VDRL, although the caveat would be that in people with otological or optic signs, bland CSF is quite common. But let’s assume that the person didn’t have either of those features. So, you can feel good that he does not have CNS involvement.

In terms of staging, then what we know for sure is that the person had a negative serological test 3 years ago, that they may have had increased risk of exposure since the relationship changed more recently. But as you mentioned before, we actually don’t know that. So, what we can say with confidence is that this person may have had syphilis for 3 years. By definition, this falls into the late bucket.

We have early, where infection has been acquired within the last 12 months, and then we have late, where the infection has been present for 1 year or more. This person falls into that late category.

The technical term that I use is latent syphilis. “Latent” means no compatible signs or symptoms that would suggest neurological, cardiac, or gummatous disease of unknown duration. So latent syphilis of unknown duration—that would be the stage. Then everything comes after that.

We’ve staged as latent syphilis of unknown duration. The treatment for that is 3 doses of long-acting injectable penicillin given once a week for 3 weeks. Or if somebody has a convincing penicillin allergy, or by choice they don’t want to receive injectable treatment, or, as we’re currently facing in the United States, the shortages of long-acting injectable penicillin. The alternative would be doxycycline, 100 milligrams twice a day for 28 days.

That’s how I would stage this individual, as latent syphilis of unknown duration, and treat with either 3 doses of Bicillin or a 28-day course of doxycycline.

Eileen:
Thank you for taking us through the staging, which is really the critical part so you can go to the guidelines (we will provide links to in the show notes). But the staging part is, again, of the artist domain.

In the last few minutes, I wanted to shift gears a little bit and see if there are any specific populations that we need to be especially thoughtful about for our screening and any trends in the prevalence or incidence of syphilis that we should be thinking about among both people living with HIV and people at risk for HIV.

Matthew:
My take home is that risk-based screening, as we talked about earlier on, has its limitations. There are so many biases that get brought in. Again, as we talked about before, I try to normalize testing for STIs. So, we’re not relying on somebody feeling confident or willing to describe in detail what their sexual behaviors are.

That being said, what we know from the epidemiology in the United States is there are 2 epidemics in syphilis. There are epidemics where the burden of infection is in men who have sex with men, and there is another epidemic where the burden of infection is in heterosexual men and women. Historically, we’ve seen that the rate of syphilis is much higher in men who have sex with men compared with other members of society. We’ve also seen very large increases in diagnosis of early syphilis in heterosexual men and women, particularly in women of reproductive age and those who are able to become pregnant. This is reflected in the very startling increases in congenital syphilis that we’ve seen here in the United States and in other parts of the world.

But to come back to your question, Eileen, I think we should be offering this test to everybody who might benefit from screening for STIs and syphilis in particular, with focus on individuals who may be at enhanced risk. Broadly, there would be individuals who have multiple sexual partners, people who will engage in condomless sex, people who may engage in transactional sex. The way that we can assist all patients, but those patients in particular, is by offering regular screening for STIs, including syphilis.

Eileen:
One thing that I can say from the inpatient medicine side is that we really never hesitate in doing syphilis screening in any older individual who presents with signs of cognitive decline. And I do feel like, exactly as you’re saying, we should potentially look for that even earlier, that as you say, risk-based screening misses a lot of people. And if we can identify this, it’s a treatable problem. Hopefully then that person doesn’t come in for the dementia workup if that was going to be, a downstream consequence. But if we apply that same lens of our willingness to send this test, and nearly anyone who ever presents with a cognitive concern in older age, we should have that willingness to do it many years before that as well.

Matthew:
Absolutely, I 100% agree. A reference screening, a treponemal test, is much less expensive than an MRI scan, for example, which is something that people who present many years after syphilis with neurological disease often end up with several MRI scans for a condition that potentially could have been avoided.

I think that screening is key. Mathematical modelling has demonstrated that screening is actually, or more regular screening, is actually one of the more effective interventions to try and bring down the burden of syphilis within society. But also applying the guidelines that already exist. In the show notes, you’ll have links to the CDC guidance and just asking ourselves and reflecting on our own practice, are we doing the basics? Are we doing the bare minimum? When we can say yes to that and feel good that we’re offering that service to everyone who would benefit, then think, are we also providing more regular screening for people who are at a stage in their life where they may be at increased risk for STIs?

The other thing to remember, too, is that in the era of really effective HIV pre-exposure prophylaxis and in the era of amazing antiretroviral therapy where undetectability is an achievable goal for most people, it’s easy to forget that there is a real synergy between bacterial STIs, syphilis, and risk of acquisition of HIV, for example. People will say to me, “Yeah, but, Matthew, times have changed. We have PrEP. We have ART, so do we really need to worry about bacterial STIs and genital inflammation as a co-factor for HIV transmission and acquisition?”

My response generally is we have access to that, and by “we,” I mean the community of practice that we work in, but not everybody does. Not everyone who needs PrEP has PrEP, not everyone who requires antiretroviral therapy both in the US and globally has access to that.

In many ways, I see curable STIs as the low-hanging fruit. The testing is straightforward. Sometimes interpreting serology can be a challenge, but that’s why people like me and people who know much more than I do are here to assist. There’s a great resource that I hope you’ll be able to put into the show notes, Eileen, the STD CCN (Clinical Consultation Network)*, which allows any provider to contact their local experts with a question about STIs, including syphilis. And somebody will respond to their question typically within 24 to 48 hours.

Eileen:
Matthew, thank you for talking about the role of STI prevention in prevention of transmission. We often talk about the community viral load and how important it is to get that as close to zero as possible, but also the community burden of STIs. That’s another thing that we should be pushing towards zero to maximize our potential to prevent onward transition.

Thank you so much, Dr. Hamill. This was an amazing brief time where we’ve addressed many of the initial questions about syphilis. We could probably talk for days about it. But I am grateful for your thoughtful practice, which is able to demystify so many things and also even speak positively about our EMRs and how their alerts can help us, which I think is a skill that really speaks to your ability to see the positives in so many things in medicine.

Matthew:
Thank you so much, Eileen. I’m glad that this was useful. And it’s been a really fantastic conversation. And congratulations on the podcast. It’s really wonderful.

Eileen:
Thanks again, Matthew, and thanks to all of our listeners. And we will see you for our next episode.

Announcer:
Thanks for listening to Viremic. If you enjoyed the show, please subscribe wherever you listen to podcasts. We’ll be back in a couple of weeks with a new case to discuss.

Viremic is sponsored by the Clinical Guidelines Program, a collaborative effort of the New York State Department of Health AIDS Institute and the Johns Hopkins University Division of Infectious Diseases.

Visit the program’s website at HIVguidelines.org.

The podcast is produced and edited by Mary Beth Hansen and Brian Hatcher with appreciated assistance from Jesse Cicotte and Laura Lebrun Hatcher.

Viremic’s case discussions are presented for informational purposes only and are not offered as medical or clinical practice advice for patients or clinicians. Any mention of specific medications or commercially available products is a description of use, not an endorsement.